Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.
Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The first part of this article looked at the basic idea of devices and computer systems that can deal with loosely connected actors, human and mechanical. This part takes it further into current experiments in health care.

These are obviously very different goals–and the device used for pulse oximetry will also be used in different ways. In a risk monitoring situation, samples may be taken less often than during a healthy fitness workout. At the minimum, a device should be configurable so that it gives the timing and accuracy needed in a particular setting. It should also be easy to turn a device on and off if it is needed for a limited time period, such as a workout.

Diego Alonso, a researcher at MD PnP, points to analgesia (the administration of pain killers) in the hospital as an example of competing needs that must be reconciled by a supervisor, human or machine. So long as the patient is stable, the pain killer should be administered. But if a monitor notices a drop in the patient’s vital signs, the painkiller’s dose must be reduced.

A popular standard for exchanging data among devices is the Data Distribution Service (DDS). The standard is rich and complex, typical of those produced by the Object Management Group. But among its virtues are an ability to specify how often you want data from a particular device. OpenICE uses DDS, among many other systems.

In short, the frequency and accuracy of data collection should be configurable. As patterns of human behavior are better understood, devices may become even more responsive to the contexts in which they are needed.

Even before the current move to standards, Capsule Tech managed to get devices to talk to EHRs through the grueling effort of interpreting the inputs and outputs of each system and crafting protocols to make them work together.

Started in 1997, the company has recently expanded from merely sharing data to developing useful tools based on data, such as alerts and a modest amount of analytics. Some of these tools demonstrate a kind of adaptability reminiscent of a human-agent collective.

For instance, alerts are crucial in any hospital environment, but notorious for crying wolf–90% can be false. In addition to sending data to the EHR, Capsule’s SmartLinx’s Medical Device Information System sends near-real-time alarm data to its Alarm Management System. This helps hospitals manage their alarms, in line with the Joint Commission’s National Patient Safety Goals.

SmartLinx does not suppress any information, but when reporting it through the Alarm Management System to the clinician’s mobile device, includes some context to help the clinician decide whether the alert needs a response. Some context involves basics such as who, where, when, and which device was activated. Other context can consist of physiological data such as the patient’s heart rate and how long the alarm has been sounding.

Additionally, to provide actionable, timely information that aids in human decision making, Capsule has built an early warning scoring system application that uses vital sign information to calculate an immediate general health status score for patients and to identify those likely to deteriorate. The application also guides the care team through appropriate actions. This may be the beginning of an intelligent, integrated health system.

Computer Systems Must Be Sensitive to Bad Input and Failure

An unfortunate tenet of human-agent collectives is that agents can’t be trusted. The most basic example is system failure. If you don’t hear from a device, does that mean the patient is fine or that the device’s battery has run out of power? DDS offers a handshake or heartbeat, the common way for distributed computing systems to determine whether part of the system has gone bust.

Provenance is another requirement for collaborative environments. This means recording when a measurement was taken, and what person or device was responsible. There must also be ways to protect against data that arrives late or is assigned the wrong timestamp. When data is entered by humans, errors can be assumed as a matter of course, even in something as simple as spelling the name of a medication manufactured by your company.

More subtle is input from inexact devices, and worse still is the potential for malicious manipulation. I heard of instances where people who got rewards by their employers for reporting exercise put their fitness devices on their dogs. Using analytics, a health care system should be able to tell that a series of sudden 20-mile-per-hour rushes interrupted by inactivity are not a human activity.

Ethical and Technical Considerations

Lots of issues come up as simple human-computer interaction evolves into collaboration among agents. I’ve already mentioned error detection and provenance. Other issues include flexibility in computers taking or relinquishing control (agile teaming), legal responsibility, providing each agent with the right incentives, considering when to engage the user’s attention (instead of taking action behind the scenes), and offering the proper interface to do so. Connected health is a deep concept offering a lot to explore, and technologies will get better as we understand more of it.

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.
Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Everyone understands that isolated interventions in the doctor’s office will not solve the chronic health conditions that plague developed nations and inflate health care costs. So as the health field shyly tries on new collaborative styles–including coordinated care, patient-centered medical homes, and accountable care organizations–participants are learning that the supporting technologies must also enable collaboration in ways vastly more sophisticated than current EHRs and devices.Read more..

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I usually don’t dig into the terminology and branding side of things. At the end of the day, for me it’s all about making sure that we understand each other. If you call something digital health or connected health or mobile health, they’re all the same genre of item. To be honest, I mostly ignore all of those words and want to know what the application actually does.

However, Neil brought up a good point in his post about the lack of consensus in his poll. Here’s his summary of the poll results:

In any case, these results, however unscientific they may be, are representative of the fact that it is so hard to reach consensus on anything in health IT. They also are symbolic of the silos that still exist in newer technologies.

Consensus in healthcare is really hard. I’m reminded of what someone at the Dell Healthcare Think Tank event I participated in said, “Healthcare is second only to florists when it comes to market fragmentation.” It’s like steering a ship with hundreds of rudders all pointing different directions. Certainly not an easy task and not something I see changing soon.

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This is a well reasoned take from John Mandrola, MD on the challenges that EMR has with many doctors. Another entry in the EHR Physician Revolt. The tone of the article is right. Dr. Mandrola isn’t against EHR and technology in general. He’s just against them in their current form. When I say current form, I suggest that is thanks to current billing requirements and other government regulations.

“Computers can turn difficult tasks into easy ones, but my EMR has taken easy tasks and made them incredibly complex.”bit.ly/WS30xY

Wouldn’t we all love an EHR that was connected? Yes, I’m using connected in the broadest terms. I’m talking about connected to patients, connected to hospitals, connected to labs, radiology, insurance companies, nurses, doctors, etc etc etc. A few of those in the list are connected, but far too many of the others aren’t.

This comment by Linda was too good not to point out. She’s right. EMR is here to stay, but the honeymoon period for EMR’s is over. Doctors are starting to ask the right questions when evaluating EHRs. This will make some EHR vendors very happy and others not as much.

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

OK, I’m probably going to raise some people’s blood pressure, but here it is: Is it possible that EMRs are a transitional technology which the industry will outgrow within the next several years?

I contend that with telemedicine expanding rapidly, connected/remote health changing the focus of care and smart phones evolving along their own path — just to name a few factors — that which we call an EMR might not be up to managing care of the future. Given the need for corporate and medical security, EMRs are also ill-equipped to give the emerging class of e-patients the data access they demand.

Yes, you can connect telehealth sites with a health system or clinic network. You can burn through developer time making sure your EMR supports the latest developments in mobile health applications. You can find ways to integrate the data generated by remote patient monitoring and make it usable. But will the final result, the application which governs all of this, be the EMR we know today?

Today’s EMR, let’s face it, is not great at connecting beyond the institution where it lives. Sure, we’re building HIEs, but there’s a reason why so many are still at an embryonic stage; forming such networks is a damnably hard job.

So what will happen when medical interactions and care shift decisively to environments and platforms outside of a hospital or clinic? I don’t know, but I think it will take a different type of system — focused on coordination rather than just data storage and analytics. It will need to be wherever patients are, collect data in whatever form it’s generated and support care delivery in ways that are in their infancy today.